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DEPARTMENT OF CONSUMER AND BUSINESS SERVICES,

WORKERS' COMPENSATION DIVISION










 

DIVISION 8
ELECTRONIC MEDICAL BILLING
436-008-0001
Authority, Applicability, Purpose,
and Administration of these Rules
(1) These rules are promulgated under
the director's authority contained in ORS 656.726(4) and specific authority under
ORS 656.252.
(2) These rules apply to
all electronic medical billing transactions generated on or after the effective
date of these rules.
(3) The purpose of these
rules is to establish uniform guidelines for the exchange of electronic medical
billing transactions within the workers' compensation system.
(4) The director may waive
procedural rules as justice requires, unless otherwise obligated by statute.
(5) Orders issued by the
division in carrying out the director's authority to enforce ORS chapter 656 are
considered orders of the director.
Stat. Auth.: ORS 656.252, 656.254 &
656.726(4)
Stats. Implemented: ORS 656.252,
656.254 & 656.726(4)
Hist.: WCD 9-2014, f. 7-14-14,
cert. ef. 1-1-15
436-008-0004
Adoption of Standards
(1) The director adopts, by reference,
the following electronic medical bill processing standards:
(a) Professional Billing:
(A) The Accredited Standards
Committee X12 (ASC X12) Standards for Electronic Data Interchange (EDI) Type 3 Technical
Reports (TR3);
(B) Health Care Claim: Professional
(837), May 2006, ASC X12, 005010X222; and
(C) Type 3 Errata to Health
Care Claim: Professional (837), June 2010, ASC X12, 005010X222A1.
(b) Institutional/Hospital
Billing:
(A) The ASC X12 Standards
for EDI TR3;
(B) Health Care Claim: Institutional
(837), May 2006, ASC X12, 005010X223;
(C) Type 1 Errata to Health
Care Claim: Institutional (837);
(D) ASC X12 Standards for
EDI TR3, October 2007, ASC X12, 005010X223A1; and
(E) Type 3 Errata to Health
Care Claim: Institutional (837), June 2010, ASC X12, 005010X223A2.
(c) Dental Billing:
(A) The ASC X12 Standards
for EDI TR3;
(B) Health Care Claim: Dental
(837), May 2006, ASC X12, 005010X224;
(C) Type 1 Errata to Health
Care Claim: Dental (837);
(D) ASC X12 Standards for
EDI Technical Report Type 3, October 2007, ASC X12, 005010X224A1; and
(E) Type 3 Errata to Health
Care Claim: Dental (837), June 2010, ASC X12, 005010X224A2.
(d) Retail Pharmacy Billing:
(A) The Telecommunication
Standard Implementation Guide, Version D, Release 0 (Version D.0), August 2007,
National Council for Prescription Drug Programs (NCPDP); and
(B) The Batch Standard Batch
Implementation Guide, Version 1, Release 2 (Version 1.2), January 2006, NCPDP.
(e) Remittance:
(A) The ASC X12 Standards
for EDI TR3, Health Care Claim Payment/Advice (835), April 2006, ASC X12, 005010X221;
and
(B) Type 3 Errata to Health
Care Claim Payment/Advice (835), June 2010, ASC X12, 005010X221A1.
(2) The director adopts,
by reference, the following electronic standards for medical bill acknowledgments:
(a) The ASC X12 Standards
for EDI TA1 Interchange Acknowledgment contained in the standards adopted under
section (1) of this rule;
(b) The ASC X12 Standards
for EDI TR3, Implementation Acknowledgment for Health Care Insurance (999), June
2010, ASC X12, 005010X231A1;
(c) The ASC X12 Standards
for EDI TR3, Health Care Claim Acknowledgment (277CA), January 2007, ASC X12, 005010X214;
and
(d) Electronic responses
to NCPDP transactions, and the response contained in the standards adopted under
subsection (1)(d).
(3) The director adopts,
by reference, the ASC X12N 275 — Additional Information to Support a Health
Claim or Encounter, Version 005010, February 2008, 005010X210, for attachments to
medical bills.
(4) The director adopts,
by reference, the ASC X12N/2013-57, effective Dec. 2013, Code Value Usage in Health
Care Claim Payments and Subsequent Claims Technical Report Type 2.
(5) ASC X12N and the ASC
X12 standards for EDI may be purchased from the ASC X12, 7600 Leesburg Pike, Suite
430, Falls Church, VA 22043; telephone 703-970-4480; and fax 703-970-4488. They
are also available for purchase through the internet at http://www.X12.org.
(6) Retail pharmacy standards
may be purchased from the NCPDP, 9240 East Raintree Drive, Scottsdale, AZ 85260,
telephone 480-477-1000; fax 480- 767-1042. They are also available, for purchase,
through the Internet at http://www.ncpdp.org.
(7) The director adopts the
Oregon Workers’ Compensation Division Electronic Billing and Payment Companion
Guide Release 1.0, Jan. 1, 2015. A copy of the guide is available at the following
website: http://www.cbs.state.or.us/wcd/operations/edi/ediindex.html.
(8) Copies of the standards
referenced in this rule are available for review during regular business hours at
the Workers’ Compensation Division, 350 Winter Street NE, Salem OR 97301,
503-947-7717.
[ED. NOTE:
Tables referenced are not included in rule text. Click here for PDF copy of table(s).]
Stat. Auth.: ORS 656.252, 656.254 &
656.726(4)
Stats. Implemented: ORS 656.252
& 656.254
Hist.: WCD 9-2014, f. 7-14-14,
cert. ef. 1-1-15
436-008-0005
Definitions
For the purpose of these rules and the
Oregon Electronic Billing and Payment Companion Guide:
(1) “Clearinghouse”
means an entity that is an authorized agent of the insurer or health care provider,
including billing services, re-pricing companies, community health management information
systems or community health information systems, and “value-added” networks
and switches that does either of the following functions:
(a) Processes or facilitates
the processing of health information received from another entity in a nonstandard
format or containing nonstandard data content into standard data elements or a standard
transaction.
(b) Receives a standard transaction
from another entity and processes or facilitates the processing of health information
into nonstandard format or nonstandard data content for the receiving entity.
(2) “Companion guide”
means the Oregon Workers’ Compensation Division Electronic Billing and Payment
Companion Guide adopted by the division in these rules that provides standards for
workers’ compensation electronic billing transactions.
(3) “Complete electronic
bill submission” means an electronic medical billing transaction that is populated
with current and valid values defined in the applicable standard set forth in OAR
436-008-0004 that:
(a) Includes the correct
billing format, with the correct billing code sets;
(b) Is transmitted in compliance
with all necessary format requirements; and
(c) Contains, in legible
text, all supporting documentation that is expressly required by law or can reasonably
be expected by the payer or its agent under the jurisdiction’s law.
(4) “Days” means
calendar days. For calendar days, the first day is not included. The last day is
included unless it is a Saturday, Sunday, or legal holiday. In that case, the period
runs until the end of the next day that is not a Saturday, Sunday, or legal holiday.
Legal holidays are those listed in ORS 187.010 and 187.020.
(5) “Director”
means the director of the Department of Consumer and Business Services.
(6) “Division”
means the Workers’ Compensation Division of the Department of Consumer and
Business Services.
(7) “Electronic”
refers to a communication between computerized data exchange systems that complies
with the standards set forth in these rules.
(8) “Explanation of
benefits (EOB)” means an electronic remittance advice (ERA) or notification,
sent or made available electronically by the insurer or an authorized agent of the
insurer, to the health care provider, health care facility, or third-party biller
or assignee regarding payment or denial of a bill, reduction of a bill, or refund.
(9) “Insurer”
means:
(a) The State Accident Insurance
Fund Corporation;
(b) An insurer authorized
under ORS chapter 731 to transact workers’ compensation insurance in Oregon;
(c) An insurer-authorized
agent or payer;
(d) An assigned claims agent
selected by the director under ORS 656.054; or
(e) An employer or employer
group that has been certified under ORS 656.430 meeting the qualifications of a
self-insured employer under ORS 656.407.
(10) “Medical Bill”
means a statement of charges for medical services.
(11) “Payer”
means the insurer or an entity authorized to make payments on behalf of the insurer.
(12) “Supporting documentation”
means those documents necessary for the insurer to process a bill, including but
not limited to medical reports and records, evaluation reports, narrative reports,
assessment reports, progress report/notes, chart notes, hospital records, and diagnostic
test results.
(13) “Trading partner”
means any entity that exchanges information electronically with another entity.
Stat. Auth.: ORS 656 252 & 656.726(4)
Stats. Implemented: ORS 656.726(4)
Hist.: WCD 9-2014, f. 7-14-14,
cert. ef. 1-1-15
436-008-0010
Electronic Medical Bills
(1) Beginning Jan. 1, 2015, insurers
must accept and process all electronically transmitted medical bills in accordance
with these rules, the standards adopted under OAR 436-008-0004, and the companion
guide.
(2) An insurer is exempt
from the requirement to accept medical bills electronically from health care providers
on or after Jan. 1, 2015, if a written notice is sent to the division, and approved
by the director, on or before close of business on Dec. 31, 2014. The notice must
explain in detail that the cost of electronic medical bill implementation will create
an unreasonable financial hardship.
(3) Health care providers
that elect to submit electronic medical bills to insurers must do so in accordance
with these rules, the standards adopted under OAR 436-008-0004, and companion guide.
(4) All electronic medical
billing transactions must be populated with current and valid values defined in
the applicable standard set forth in OAR 436-008-0004.
(5) The health care provider,
health care facility, third-party biller or assignee and the insurer may mutually
agree to use nonstandard formats, but those formats must include all data elements
required under the applicable standard, as set forth in OAR 436-008-0004.
(6) Health care providers
and insurers may contract with other entities for electronic medical bill processing.
(7) Insurers and health care
providers are responsible for the acts or omissions of their agents executed in
the performance of electronic medical billing services.
(8) The data elements transmitted
as part of a Trading Partner Agreement must at a minimum contain all the same required
data elements found within the ASC X12 Type 3 Technical Reports and the jurisdiction-specific
companion guide.
Stat. Auth.: ORS 656.252, 656.254 &
656.726(4)
Stats. Implemented: ORS 656.252
& 656.254
Hist.: WCD 9-2014, f. 7-14-14,
cert. ef. 1-1-15
436-008-0015
Electronic Medical Bill Attachments
or Documentation
(1) A unique attachment indicator number
must be assigned to all documentation. The attachment indicator number populated
on the document must include the report type code, the report transmission code,
the attachment control qualifier, and the attachment control number.
(2) Documentation in support
of electronic medical bills may be submitted by fax, secure email, regular mail,
electronic transmission using the prescribed format, or by a mutually agreed upon
format.
(3) Documentation in support
of electronic medical bills must be submitted within five days of submission of
the bill and include the following elements:
(a) Patient name (ill or
injured worker);
(b) Date of birth (if available);
(c) Employer name;
(d) Insurer name;
(e) Date of service;
(f) Claim number (if no claim
number then use “UNKNOWN”); and
(g) Unique attachment indicator
number.
Stat. Auth.: ORS 656.252, 656.254 &
656.726(4)
Stats. Implemented: ORS 656.252
& 656.254
Hist.: WCD 9-2014, f. 7-14-14,
cert. ef. 1-1-15
436-008-0020
Electronic Medical Bill Acknowledgements
(1) If the electronic submission does
not conform to the standards adopted under OAR 436-008-0004(1), then the insurer
must send an acknowledgment adopted under 436-008-0004(2)(a) or 436-008-0004(2)(b)
to the health care provider. This acknowledgement must be sent within one day of
receipt of the electronic bill unless the electronic submission lacks sufficient
identifiers to create an acknowledgment.
(2) If the electronic submission
does conform to a standard adopted under OAR 436-008-0004(1), then the insurer must
send an acknowledgment adopted under 436-008-0004(2)(c) to the health care provider
within two days.
(3) Any acknowledgment of
a medical bill, as provided in (1) or (2) of this rule is not an admission of liability
by the insurer.
Stat. Auth.: ORS 656.252, 656.254 &
656.726(4)
Stats. Implemented: ORS 656.252
& 656.254
Hist.: WCD 9-2014, f. 7-14-14,
cert. ef. 1-1-15
436-008-0025
Electronic Medical Bill Payments
(1) Insurers that accept and process
a complete electronic bill for services, under OAR 436-008-0010(1)(a) or (b), must
pay for treatment related to the injury or disease, provided or authorized by the
treating health care provider, on accepted claims within 14 days of any action causing
the service to be payable, or within 45 days of receipt of the electronic bill,
whichever is later.
(2) If an insurer requires
additional information before a payment decision can be made, a request for this
information must be made to the medical provider within 20 days of receipt of the
bill.
(3) The insurer must provide
an explanation (EOB) of services being paid or denied.
Stat. Auth.: ORS 656.252, 656.254 &
656.726(4)
Stats. Implemented: ORS 656.252
& 656.254
Hist.: WCD 9-2014, f. 7-14-14,
cert. ef. 1-1-15
436-008-0030
Electronic Remittance Advice; Explanation
of Benefits
(1) An electronic remittance advice
(ERA) or notification is an explanation of benefits (EOB) that the insurer submits
electronically regarding payment or denial of a bill, reduction of a bill, or refund.
An insurer must submit an EOB no later than five days after generating a payment.
(2) The EOB must include:
(a) The amount of payment
for each service billed. When the payment covers multiple patients, the explanation
must clearly separate and identify payments for each patient;
(b) The specific reason for
non-payment, reduced payment, or discounted payment for each service billed; and
(c) An Oregon or toll-free
phone number for the insurer or its representative, and a statement that the insurer
or its representative must respond to a health care provider’s payment question
within 48 hours, excluding weekends and legal holidays.
(3) The insurer must make
available, to health care providers, the applicable information specified under
OAR 436-009-0030(3)(c)(A) through (F), including:
“If you disagree with
this decision about this payment, please contact {the insurer or its representative}
first. If you are not satisfied with the response you receive, you may request administrative
review by the director of the Department of Consumer and Business Services. Your
request for review must be made within 90 calendar days of the send/receive date
of this explanation. To request a review, provide information that shows what you
believe is incorrect about the payment, and send this information and required supporting
documentation to the Workers’ Compensation Division, Medical Resolution Team,
P.O. Box 14480, Salem, OR 97309-0405. You may fax the request to the director at
503-947-7629. You must also send a copy of the request to the insurer. You should
keep a copy of this information for your records.”
(4) Any information required
under sections (1) through (3) of this rule that cannot be submitted on the electronic
EOB must be made available on the insurer’s website or by any other means
reasonably convenient for the EOB recipient.
Stat. Auth.: ORS 656.252, 656.254 &
656.726(4)
Stats. Implemented: ORS 656.252
& 656.254
Hist.: WCD 9-2014, f. 7-14-14,
cert. ef. 1-1-15
436-008-0040
Assessment of Civil Penalties
Under ORS 656.745, the director may
assess a civil penalty against an insurer that fails to comply with ORS Chapter
656, the director’s rules, or orders of the director.
Stat. Authority: ORS 656.726(4)
Stat. Implemented: ORS 656.254
& 656.745
Hist.: WCD 9-2014, f. 7-14-14,
cert. ef. 1-1-15

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